<html>
<head>
<title>User Feedback Form</title>
</head>

<form method="post" enctype="multipart/form-data" action="secuform.php">
<input type="hidden" name="MAX_FILE_SIZE" value="1000000">
<input type="hidden" name="path_to_file" value="/www/uploaded/files">
<input type="hidden" name="require" value="email,phone_no">
<input type="hidden" name="recipient" value="your@email.com">
<input type="hidden" name="sort" value="alphabetic">
<input type="hidden" name="ar_file" value="autoresponder.txt">
<input type="hidden" name="ar_subject" value="VINL User Feedback!">
<input type="hidden" name="env_report" value="REMOTE_HOST,HTTP_USER_AGENT">
<table>
<h1 align="center">VINL User Feedback Form</h1>
 <tr>
  <td>
  	  Are you a (check all that apply): <br>
      Admin:  <input type="checkbox" name="Role[]" value="Admin"><br>
      Teacher: <input type="checkbox" name="Role[]" value="Teacher"><br>
      Student: <input type="checkbox" name="Role[]" value="Student"><br>
      Guest: <input type="checkbox" name="Role[]" value="Guest"><br><br>
  </td>
 </tr>
 <tr>
  <td>Your Email:</td><td><input type=text name="email"></td>
 </tr>

 <tr>
  <td>Comments: </td><td><textarea name="Comments" cols="40" rows="3"></textarea></td>
 </tr>
 <tr>
  <td colspan="2"><input type="submit"><input type="reset"></td>
 </tr>
</table>

<p>&nbsp;</p>
<p><br>
    <br>
</p>
<hr>

</form>

</html>
<!--This form is powered by <a href="http://www.dtheatre.com/scripts/">Jack's Formmail.php!</a> -->